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Sleep strategies. The older you get, the more elaborate they become. Look at me, age 56, a virtual insomniac, increasingly so for years now. Because once I lie down, there's the chronic back pain -- and, even worse, the racing mind, focused on my Silicon Valley work routines, the hyper-striving, the deadlines. What will the morning bring? Enough worries to make sleep impossible, and so I strategize.
For a while, that meant nights at the gym, a way to tire myself out before sleep; it only got me wired. I tried a glass of wine at bedtime, but that just dried me out, made my legs jumpy in bed. I listened to music on my iPod in the dark, but that only focused my brain; I write about music for a living, for this newspaper. So I turned off the music and tried counting backward from 1,000. And finally, there were early evening catnaps on the living room sofa, after I recognized, perhaps subconsciously, that the bed was the place where I inevitably would just lie for hours in the middle of the night, trying to will myself to sleep, dozing off now and then, only to be awakened by distant voices -- coming from my wife's ear buds, as she tried and failed to put herself to sleep by listening to BBC podcasts on her iPod.
Finally, about six weeks ago, I broke down, popped an Ambien and imagined myself passing through the magic portal to a full eight hours of unconsciousness. I woke up after 90 minutes.
It felt like a crisis, the end of sleep -- emblematic
of life in the valley, the busy-bee land of perpetual work, if you're lucky enough to still have it in a time of economic woe. Studies show that 20 percent of Americans sleep less than six hours per night, that insomnia is associated with absenteeism and reduced productivity on the job, and that it constitutes a public health risk with attendant costs of about $100 billion annually in the U.S., by some estimates.Who sleeps anymore? I've discovered that many of my friends fight to sleep. One swears by Ambien. Half a pill nightly, and he's down for the count, restored by morning when the next monster deadline approaches in his job as a tech writer. Another swears that Excedrin PM, available over the counter, is all he needs to tumble toward sleep. His wife does gentle yoga stretches in bed when sleep eludes her. Yet another friend elbows her husband, at any hour, and says, "Read to me." Which he does.
Lights on. No one's sleeping.
And so I stopped by the Stanford Hospital's Sleep Disorders Clinic in Redwood City, looking for some answers.
There are other sleep clinics around the Bay Area, including in Santa Clara (operated by Kaiser), Fremont and at UC San Francisco. But Stanford's is especially renowned. It tallies about 7,500 visits a year, and many of the people who walk through its doors wind up speaking with Dr. Allison T. Siebern, associate director of Stanford's Insomnia and Behavioral Sleep Medicine Program. For about an hour, she became my sleep guru, filling in the basics.
Siebern explained that there are 90 or so sleeping disorders, including narcolepsy and sleep apnea. But insomnia is most common. For 10-15 percent of Americans, it is a full-blown disorder with a cluster of chronic symptoms: the persistent problems of getting to sleep or staying asleep, coupled with a diminished sense of well-being and a falloff in daytime functioning. Beyond this core group, research shows that 30-80 percent of Americans at one time or another suffer from symptoms of insomnia.
"Our culture's changing," Siebern told me. "We are 24/7. People are so plugged in. There's no transition time, no getting ready for sleep."
She paused and said, "So you're awake in the middle of the night."
I am.
"And you're coming up with all these strategies to bring on the sleep."
It's true.
"But you can't will it on. It's like chasing your own shadow."
Bingo. The more you try to sleep, the less you sleep. It's always just out of reach.
I explained my work routines to Siebern: the erratic hours, the burning of the candle at both ends, the late-night concerts and early-morning deadlines. Like so many people in the valley, she said, my shifting work schedule leaves me feeling "perpetually jet-lagged. It's like you're always going to a different time zone. You experience this de-synchrony," and it doesn't help sleep.
She pulled out a chart, illustrating the body's internal "circadian clock" and its competing drives for sleep and wakefulness. (These and other concepts are further explained at a website developed by Dr. Rachel Manber, the sleep clinic's director: http://knol.google.com/k/ insomnia). Typically, the "sweet spot" for sleep happens some time in the evening, as the hunger for sleep increases and the brain's wakefulness signals taper off.
"And then a mountain lion walks into the room," Siebern said, speaking figuratively.
The mountain lion might be anxiety over work or a pre-bedtime spat with a spouse, whatever lingers in the psyche and rouses one from sleep. Over time, "the very fear of not sleeping becomes the mountain lion," breaking into the sleep cycle, again and again. Eventually, the bed -- the place where you tough it out, fighting to sleep -- becomes "a cue for wakefulness. For some people, just going into the bedroom becomes the cue. Just seeing the bed, they experience dread. The night time isn't so pleasant."
You may have read about sleep hygiene: Cut back the caffeine, don't get into bed at 9 p.m. if you never fall asleep before 1 a.m. These are helpful suggestions and can help good sleepers maintain their regimen. But there's no silver bullet for insomniacs.
There is, however, cognitive behavioral therapy for insomnia (CBTi), a medication-free program practiced at Stanford, where Siebern and the rest of the staff function, in effect, as personal trainers for sleep-deprived clients. (Patients who take sleep medication can still take the program, which will help them taper off and eliminate the medication, if they so choose.) To understand how the therapy works, I called Elena Gonzales, a clinical psychologist and sleep specialist in Point Richmond, who trained at Stanford's clinic and maintains an adjunct position there.
"We live in a culture where everyone wants to have whatever they want, right away," she said. "And there is such a sense of injury and deprivation whenever someone isn't sleeping. It's like, 'What?' "
Let it rest. Quit being "hyper-organized" around your sleep; that's key, she told me. "Try to calm the mind and relax the body," but without the intention of controlling the onset of sleep. You might watch some TV before bedtime, read a magazine -- nothing too heavy -- or just spend some quiet time with your spouse or partner. Long-term, yoga is good, as are mindfulness meditation and other stress-reduction practices.
If sleep still proves elusive, maybe it's time for CBTi: A patient will discuss his thoughts and beliefs about sleep with the therapist over the course of six or eight weekly sessions. (They are typically, but not always, covered by health insurance.) This is the cognitive piece: Those middle-of-the-night fears about tomorrow's disaster at the office are understandable, but perhaps exaggerated.
Patients also will go through a tough-love sleep restriction program. This is the behavioral piece: At the outset of treatment, time in bed at home will be cut back in order to increase the craving for sleep -- and to consolidate sleep, to make it less fragmented. After a week, a patient might be sleeping five hours at a stretch. The next week, he or she might be instructed to get into bed 15 minutes earlier, gradually building the sleep and establishing, where possible, a consistent wake-up time.
And as said, if they have been taking sleep medications, patients are generally weaned from them. There is a solid body of research comparing the treatment of patients with prescription sleep medicines and with CBTi; CBTi takes longer to kick in, but it is durable, with longer-lasting effects.
"We're empowering people with tools," Gonzales said, "so they can be self-changers."
I haven't enlisted for therapy, but I'm trying to be my own self-changer. With a year-old yoga practice, my back pain has all but disappeared. And that mountain lion hasn't been around lately. That may be because my sleepless wife and I have a new dog, big and goofy -- and a barker, vigilant. She patrols the house, watches out for us, and, to my utter amazement, the sound of Zella's gentle snoring on the floor beside my bed is a sleep inducer. My sleep has grown more consolidated. Less fragmented. More relaxed. And I'm not even trying.
Contact Richard Scheinin at 408-920-5069.Sleep medicationsThe National Sleep Foundation estimates that 25 percent of Americans take some type of medication every year to help them sleep. Prescription medicines that promote sleep are known as "hypnotics." Ambien is a hypnotic and is considered safe when taken as directed.Intended for short-term insomnia, it is promoted as having few side effects when compared with other sleeping pills. Dizziness is the side effect most often reported. And there is that well-publicized problem of "complex sleep-related behaviors," as the Food and Drug Administration put it.
While rare, these behaviors include everyday activities such as driving, making phone calls and raiding the refrigerator -- all while fast asleep. Hence the sobriquet "Ambien Zombies."
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